Speech-Language Pathology & Audiology - Responsibility ...

1 BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GAVIN NEWSOM, GOVERNOR Speech-Language Pathology & Audiology & HEARING AID DISPENSERS BOARD 1601 RESPONSE ROAD, SUITE 260, SACRAMENTO, CA 95815 PHONE (916) 287-7915 Responsibility STATEMENT FOR SUPERVISORS OF A Speech-Language Pathology ASSISTANT INSTRUCTIONS: Complete the following sections; read the statements and sign on page 2. This form must be submitted within 14 business days from the start date of supervision. Do not use white out or fax this form. PART A: Speech-Language Pathology ASSISTANT INFORMATION 1. FULL LEGAL NAME:LAST FIRST MIDDLE 2. Speech-Language Pathology ASSISTANT LICENSE NUMBER3. STREET ADDRESS: CITY, STATE, ZIP CODE: ADDRESS:PART B: SUPERVISOR INFORMATION 1.

2 FULL LEGAL NAME OF SUPERVISOR: LAST FIRST MIDDLE 2. Speech-Language Pathology LICENSE NUMBER OR CLEAR CREDENTIAL ISSUE DATE3. STREET ADDRESS:CITY, STATE, ZIP CODE: 4. EMAIL ADDRESS: Refer to Title 16, California Code of Regulations, Section for supervisor s responsibilities. PART C: SUPERVISION 5. DATE SUPERVISION BEGAN: (MM/DD/YY)6. ARE YOU SUPERVISING AN ASSISTANT WHO HAS MORE THAN ONE SUPERVISOR? YES NOIf yes, please indicate whether you will be the supervisor designated as the lead supervisor for the purposes of assisting thespeech- language Pathology assistant in his or her compliance with the continuing professional development requirement pursuantto section of the California Code of Regulations. YES NO[SPA 110/REV 01/16] Page 1 of 3 Speech-Language Pathology ASSISTANT Duties and Responsibilities of Speech-Language Pathology Assistant Division of Title 16, California Code of Regulations Section requires that any qualified Speech-Language pathologist who assumes Responsibility for providing supervision to a registered Speech-Language Pathology assistant to complete and sign under penalty of perjury, the following statement.

3 1)I have read and understand the excerpts of the laws and regulations, included with my application, pertaining to theresponsibilities of a Speech-Language Pathology )My supervisor shall maintain a current license issued by the Board, during the time of my supervision. If mysupervisor s license expires during the course of professional experience, I will immediately notify the board. Asupervisor s license can be verified at any time at the Board s SIGNATURE PRINTED NAME OF APPLICANT DATE Duties and Responsibilities of Supervisor Division of Title 16, California Code of Regulations Section requires that any qualified Speech-Language pathologist who assumes Responsibility for providing supervision to a registered Speech-Language Pathology assistant to complete and sign under penalty of perjury, the following statement. 1)I possess the following qualification to supervise an aide applicant: a current valid Speech-Language Pathologylicense issued by the Board.

4 Or (if employed by a public school) a valid, current , and professional clear credentialauthorizing service in language , speech , and hearing issued by the Commission on Teacher )I agree to ensure that either my California licensee or my clear credential is renewed in a timely )I will immediately notify the assistant of any disciplinary action, including revocation, suspension (even if stayed),probation terms, inactive license, or lapse in licensure that affects my ability or right to )I will maintain records of course completion for a period of two years from the assistant registration renewal )I will complete no less than six (6) hours of continuing a professional development in supervision training in the initialtwo year period from the commencement of supervision, and three (3) hours in supervision training every two yearsthereafter pursuant to Section (b)(4) of the California Code of )I have read and understand the laws and regulations pertaining to the supervision of assistants and the experiencerequired for registration as an )I will ensure that the extent, kind, and quality of the clinical work performed are consistent with the training andexperience of the assistant and shall be accountable for the assigned tasks performed by the )I will review client/patient records, monitor and evaluate assessment and treatment decisions of the assistant, monitorand evaluate the ability of the assistant to provide services at the site(s) where he or she will be practicing and to theparticular clientele being treated, and ensure compliance with all laws and regulations governing the practice ofspeech- language )I will assist with the development of a plan for the assistant to complete twelve (12)

5 Hours of continuing professionaldevelopment every two years, through state or regional conferences, workshops, formal in-service presentations,independent study programs, or any combination of these, concerning communication )I will discuss with the assistant the manner in which emergencies will be handled.[SPA 110/REV 7/15] Page 2 of 3 Duties and Responsibilities of Supervisor cont d 11)I will provide this Board with this original signed form within 14 calendar days of commencement of any supervision. Iwill provide a copy of this form to the )Upon written request of the Board, I will provide to the Board any documentation, which verifies my compliance withthe requirements set forth in this )I will not supervise more than three (3) support personnel, not more than two of which hold the title of Speech-Language Pathology )At the time of termination of supervision, I will complete the Termination of Supervision form 77ST(new 12/99).

6 I willsubmit the original signed form to the Board within fourteen (14) calendar days of termination of OF SUPERVISOR PRINT FULL LEGAL NAME OF SUPERVISOR LICENSE NUMBER OR CREDENTIAL NUMBER DATE (Please attach a copy of the front and back of your credential) [SPA 110/REV 7/15] Page 3 of 3